P6142LATIN telemedicine - expanded umbrella of cost-effective ami coverage for 100 million people

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M A Torres ◽  
S Mehta ◽  
R Botelho ◽  
F Fernandez ◽  
J Cade ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Cost Effective ◽  
Developed Countries ◽  
Population Based ◽  
Primary Pci ◽  
Hub And Spoke ◽  
Web Based ◽  
Catheterization Laboratory ◽  
Number Of Patients ◽  
And Training

Abstract Background AMI is a unique entity where the immediate diagnosis can be made by a single test, the EKG. Despite this matchless attribute of easy diagnosis, developing (and some developed) countries lack resources and efficient pathways for urgent and reliable diagnosis of AMI. With Latin Telemedicine Infarct Network (LATIN), we have previously presented Telemedicine as a pragmatic solution for urgent and accurate diagnosis of AMI. In this work, we reveal pathways of scalable population-based AMI management models. Purpose To utilize telemedicine as a foundation pillar for creating cost-effective and global models of AMI management. Methods LATIN pilot tested the hypothesis of remote guidance of AMI management and expanded access by creating a hub and spoke, STEMI systems of care that exploited regional resources. A highly efficient, web-based, cloud-computing prototype was developed and scrupulously monitored with a new metric of time to telemedicine diagnosis (TTD). STEMI systems of care were created to efficiently triage the diagnosed patients for being treated with thrombolysis, pharmaco-invasive management or Primary PCI. This stratagem had enormous provincial variability and was constrained mainly by ambulance structure. Telemedicine and IT costs were forced lower and enabled a cost-effective process to hugely provide access to 100 million patients located in poorer regions of Colombia, Brazil, Mexico, and Argentina. Education and training have formed the mantra for LATIN and stakeholder development, and ambulance systems development has remained immutable goals. Results Almost 800,000 patients were successfully screening through LATIN with a cost for accurate STEMI diagnosis of < $3, a tele accuracy that exceeded 95% and with TTD <4 minutes. A total of 8,440 (1.1%) of patients were diagnosed with AMI in this manner and 3,924 (46.5%) urgently reperfused, mainly with Primary PCI (3,048, 77.8%). D2B times have been lowered now to 51 minutes but this is fortuitous, as several PCI-capable facilities are small, and direct transfer to the catheterization laboratory is easy. Door in and Door out times and transport times remain high as a large number of patients are denied by insurance and other payers for treatment. Overall, mortality is 5.2%. Conclusions Global financial and philanthropic institutions should contemplate models analogous to LATIN for saving the lives of millions of poor patients in developing countries from AMI.

P3352Telemedicine transcends national boundaries in quest of creating a behemoth ami program

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Mehta ◽  
R Botelho ◽  
F Fernandez ◽  
F Feres ◽  
A Abizaid ◽  
...  
Keyword(s):  
Community Health Centers ◽  
Developed Countries ◽  
Population Based ◽  
Primary Pci ◽  
Small Community ◽  
Hub And Spoke ◽  
Web Based ◽  
National Boundaries ◽  
Intelligent Tools ◽  
Time Of Presentation

Abstract Background The Latin America Telemedicine Infarct Network (LATIN) has exploited the remarkable competence of telemedicine for remote guidance. In doing so, LATIN created a mammoth population-based AMI network that employed experts located several hundred miles away to guide the reperfusion strategies for almost 800,000 screened patients. In this pioneering project, telemedicine was initially utilized to guide AMI management within national confines. We speculated whether LATIN telemedicine navigation could outstrip countrywide borders. Purpose To maximally harness the vast possibilities of telemedicine for improving AMI care. Methods During its pilot phase, LATIN began as a hub and spoke, AMI system in Colombia where 20 spokes (small community health centers and rural clinics) were configured with 3 hubs that could perform Primary PCI. These sites were linked through web-based connectivity. Expert cardiologists, located 50–250 miles away in Bogota, Colombia, used sophisticated telemedicine platforms for urgent EKG diagnosis and teleconsultation of the entire AMI process. Based upon the duration of chest pain and travel time to the hub, these experts guided patients through guideline-based strategies of thrombolysis, pharmaco invasive management or primary PCI. Efficiency of the telemedicine process was measured with the new metric of time to telemedicine diagnosis (TTD). Cloud computing, GPS navigation, and numerous business intelligent tools were gradually incorporated into LATIN telemedicine. As systems became more scalable, the program was expanded to Brazil, where LATIN flourished. Over the last 18 months, LATIN telemedicine capabilities have been pressed across national boundaries. Presently, all 82 LATIN centers in Mexico are guided by experts located in Bogota, Colombia and the 7 Argentina centers channeled through Santiago, Chile. Results 784,947 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). Navigation pathways are depicted in the attached figure. TTD remains extremely low in all four countries, and comparable efficiency and tele-accuracy have been achieved. With expanded geographic reach, 8,448 (1.08%) patients were diagnosed with STEMI and 3,911 (46.3%) urgently reperfused, including 3,049 (78%) with Primary PCI. Time to TTD ranged between 2.8 to 5.8 minutes, with a mean of 3.5 min. Tele-accuracy was 98.5%, D2B 51 min, and in-hospital mortality 5.2%. Various other comparative metrics for the 4 countries are being gathered and will be available at the time of presentation. Conclusions LATIN demonstrates the robust ability of telemedicine to transcend national boundaries to guide AMI management. This strategy can be adopted in under-developed countries in Asia and Africa to provide an umbrella of AMI care for the millions of disadvantaged patients.

scholarly journals Management of Hypertension: A Bangladeshi Perspective

1970 ◽  
Vol 39 (1) ◽  
pp. 40-43
Author(s):  
SM Mustafa Zaman ◽  
Mohammad Salman ◽  
Kaniz Fatema
Keyword(s):  
Cardiovascular Disease ◽  
Fruits And Vegetables ◽  
Lifestyle Modification ◽  
Clinical Care ◽  
Cost Effective ◽  
Developed Countries ◽  
Population Based ◽  
Lifestyle Changes ◽  
Optimum Level ◽  
Lifestyle Modifications

Hypertension is a silent killer. Bangladeshis are racially predisposed to cardiovascular disease, and the increasing burden of hypertension has only added to the problem. Economic constraints and the allure of additional benefits without adverse effects have made lifestyle modifications an attractive proposition in developing and developed countries alike. Blood pressure is a continuum and any increase above optimum level confers additional independent risk of cardiovascular disease. We review screening, diagnosis and management using lifestyle measures and pharmacotherapy. We then discuss the barriers and challenges to implementing this approach and what can be done regarding prevention, screening, lifestyle modification and pharmacotherapy in our country. By adopting a comprehensive population based approach including policy level interventions directed at promoting lifestyle changes; a healthy diet (appropriate calories, low in saturated fats and salt and rich in fruits and vegetables), increased physical activity, and a smoking free society, properly balanced with a high risk approach of cost effective clinical care, Bangladesh can effectively control hypertension and improve public health. DOI: 10.3329/bmj.v39i1.6232 Bangladesh Medical Journal 2010; 39(1): 40-43

Frequency, predictors, and outcomes of readmission to index versus non-index hospitals after mechanical thrombectomy in patients with ischemic stroke

2019 ◽  
Vol 12 (2) ◽  
pp. 136-141 ◽  
Author(s):  
Kristina Shkirkova ◽  
Michelle Connor ◽  
Krista Lamorie-Foote ◽  
Arati Patel ◽  
Qinghai Liu ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Systems Of Care ◽  
Multivariable Logistic Regression Analysis ◽  
Complication Rates ◽  
Hub And Spoke ◽  
Vast Number ◽  
Number Of Patients ◽  
Index Hospital

BackgroundStroke systems of care employ a hub-and-spoke model, with fewer centers performing mechanical thrombectomy (MT) compared with stroke-receiving centers, where a higher number offer high-level, centralized treatment to a large number of patients.ObjectiveTo characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT.MethodsThis study leveraged a population-based, nationally representative sample of patients with stroke undergoing MT from the Nationwide Readmissions Database between 2010 and 2014. Descriptive, logistic regression analyses, and univariate and multivariate logistic regression models were carried out to determine patient- and hospital-level factors, mortality, complications, and subsequent readmissions associated with index and non-index hospitals' 90-day readmissions.ResultsIn the study, 2111 patients with a stroke were treated with MT, of whom 534 were readmitted within 90 days. The most common reasons for readmission were: septicemia (5.9%), atrial fibrillation (4.8%), and cerebral artery occlusion with infarct (4.8%). Among readmitted patients, 387 (74%) were readmitted to index and 136 (26%) to non-index hospitals. On multivariable logistic regression analysis, non-index hospital readmission was not independently associated with major complications (p=0.09), mortality (p=0.34), neurological complications (p=0.47), or second readmission (p=0.92).ConclusionOne-quarter of patients with a stroke treated with MT were readmitted within 90 days, and one quarter of these patients were readmitted to non-index hospitals. Readmission to a non-index hospital was not associated with mortality or increased complication rates. In a hub-and-spoke model it is important that follow-up care for a specialized procedure can be performed effectively at a vast number of non-index hospitals covering a large geographic area.

scholarly journals Sodium Consumption: An Individual's Choice?

2012 ◽  
Vol 2012 ◽  
pp. 1-6 ◽  
Author(s):  
Norm R. C. Campbell ◽  
Jillian A. Johnson ◽  
Tavis S. Campbell
Keyword(s):  
Developing Economies ◽  
Behavioural Change ◽  
International Health ◽  
Cost Effective ◽  
Developed Countries ◽  
Population Based ◽  
Dietary Salt ◽  
Dominant Source ◽  
International Health Organizations ◽  
Improve Health

Excess intake of dietary salt is estimated to be one of the leading risks to health worldwide. Major national and international health organizations, along with many governments around the world, have called for reductions in the consumption of dietary salt. This paper discusses behavioural and population interventions as mechanisms to reduce dietary salt. In developed countries, salt added during food processing is the dominant source of salt and largely outside of the direct control of individuals. Population-based interventions have the potential to improve health and to be cost saving for these countries. In developing economies, where salt added in cooking and at the table is the dominant source, interventions based on education and behaviour change have been estimated to be highly cost effective. Regardless, countries with either developed or developing economies can benefit from the integration of both population and behavioural change interventions.

Maximum artificial intelligence and complete reconstruct of population-based AMI care

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Mehta ◽  
M Gibson ◽  
S Niklitschek ◽  
F Fernandez ◽  
C Villagran ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Cost Savings ◽  
Population Based ◽  
Funding Source ◽  
Primary Pci ◽  
Hub And Spoke ◽  
Door To Balloon ◽  
Time Of Presentation ◽  
Gradual Release ◽  
Overall Mortality

Abstract Background After creating a behemoth hub and spoke AMI network that encompasses more than 100 million patients in 5 countries, we have begun to incorporate Artificial Intelligence (AI) algorithms into our telemedicine strategy with the goal of creating comprehensive, very early AMI diagnosis and physician-free triage. In doing so, we have replaced door-to-balloon times (d2b) with symptom-to-balloon times (s2b) as an immutable objective. Purpose To incorporate AI attributes for very early AMI detection, triage, and management. Methods We expanded our effective telemedicine strategy (100 million population; 877,178 telemedicine encounters; 55% overall mortality reduction; $291 million cost savings) with a logistic reset to impact s2b. To do this, we incorporated our Single Lead 1.0 (lead I) and Single Lead 2.0 (lead V2) technology for self-administered AMI detection with our physician-free STEMI diagnosis and triage AI algorithms. Single Lead algorithms and physician-free protocols were generated by utilizing Machine Learning from our mammoth annotated EKG repository. Results In addition to three logistic markers of efficiency Time-to-Telemedicine Diagnosis (TTD), Door-In-Door-Out (DIDO) and Transfer Times (TT); we are monitoring s2b. A gradual release of the algorithms and single lead is occurring at the telemedicine spokes. Detailed results will be available at the time of presentation. Conclusions Impacting s2b, the Achilles Heel of Primary PCI, may be achieved with the use of patient-administered AMI detection tools. Incorporation of these technologies into AI algorithms will add to telemedicine efficiencies for population-based AMI care. Funding Acknowledgement Type of funding source: None

scholarly journals A Web-Based Dementia Education Program and its Application to an Australian Web-Based Dementia Care Competency and Training Network: Integrative Systematic Review

10.2196/16808 ◽  
2020 ◽  
Vol 22 (1) ◽  
pp. e16808 ◽  
Author(s):  
Anne Moehead ◽  
Kathryn DeSouza ◽  
Karen Walsh ◽  
Sabrina W Pit
Keyword(s):  
Education Program ◽  
Cost Effective ◽  
Dementia Care ◽  
Web Based ◽  
Web Based Learning ◽  
Key Features ◽  
Kirkpatrick’S Model ◽  
And Training ◽  
Web Based Education ◽  
Dementia Education

Background Dementia education that meets quality and safety standards is paramount to ensure a highly skilled dementia care workforce. Web-based education provides a flexible and cost-effective medium. To be successful, Web-based education must contain features that promote learning and support knowledge translation into practice. The Dementia Care Competency and Training Network (DCC&TN) has developed an innovative Web-based program that promotes improvement of the attitudes, knowledge, skills, behavior, and practice of clinicians, regardless of their work setting, in order to improve the quality of life for people living with dementia. Objective This review aims to (1) determine the key features that are associated with an effective and functional Web-based education program—an effective and functional Web-based program is defined as one that measures results, is accessible, is user friendly, and translates into clinical practice—and (2) determine how these features correlate with the DCC&TN. Methods Six electronic databases—Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), AusHealth, Nursing@Ovid, and Google Scholar—were searched for articles published between 2009 and 2018 using the following keywords: Education, Distance, Continuing, Learning, Online, Web-Based, Internet, Dementia, Program Evaluation, Validation Studies, Outcome and Process Assessment Healthcare, Nursing, Assisted Instruction, and Facilitated. The Critical Appraisal Skills Programme (CASP) and Kirkpatrick’s model for the evaluation of training were used to ensure quality and rigor of the analysis. Results A total of 46 studies met the inclusion criteria. In total, 14 key features were associated with an effective Web-based learning environment, which enabled the environment to be as follows: self-directed, individualized, interactive, multimodal, flexible, accessible, consistent, cost-effective, measurable with respect to participant satisfaction, equitable, facilitated, nurturing of critical thinking and reflection, supportive of creating a learning community, and translated into practice. These features were further categorized into five subgroups: applicability, attractiveness, functionality, learner interaction, and implementation into practice. Literature frequently cites Kirkpatrick’s four-level model of evaluation and application in the review of education and training; however, few studies appeared to integrate all four levels of Kirkpatrick’s model. Features were then correlated against the DCC&TN, with an encouraging connection found between these features and their inclusion within the content and structure of the DCC&TN. Conclusions A total of 14 key features were identified that support an effective and functional Web-based learning environment. Few studies incorporated Kirkpatrick’s salient elements of the model—reaction, learning, behavior, and results—in their evaluation and clinical application. It could, therefore, be considered prudent to include Kirkpatrick’s levels of training evaluation within studies of dementia training. There were few studies that evaluated Web-based dementia education programs, with even fewer reporting evidence that Web-based training could increase staff confidence, knowledge, skills, and attitudes toward people with dementia and be sustainable over time. The DCC&TN appeared to contain the majority of key features and is one of the few programs inclusive of hospital, community, and residential care settings. The 14 key features can potentially enhance and complement future development of online training programs for health sciences education and beyond. The DCC&TN model could potentially be used as a template for future developers and evaluators of Web-based dementia training.

P1928Global telemedicine initiatives for combating ami

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Mehta ◽  
R Botelho ◽  
S Niklitzchek ◽  
F Fernandez ◽  
J Cade ◽  
...  
Keyword(s):  
Developing Countries ◽  
Population Based ◽  
Health Centers ◽  
Primary Pci ◽  
Hub And Spoke ◽  
Ambulance Dispatch ◽  
Primary Care Health ◽  
Remote Sites ◽  
Care Health ◽  
Cost Efficient

Abstract Background Major disparities exist between developed and developing countries in Acute Myocardial Infarction (AMI) outcomes. Telemedicine has emerged as a powerful, cost-efficient, and scalable tool for population-based AMI management. We propose efficient telemedicine protocols as frontline AMI strategies for resource-constrained developing countries. Purpose To create a global template of using telemedicine protocols for treating AMI. Methods A hub and spoke strategy was utilized for Latin America Telemedicine Infarct Network (LATIN) to expand access in Brazil, Colombia, Mexico, and Argentina. Small clinics and primary care health centers in remote areas were strategically connected with 24/7 primary PCI facilities. Experts at 4 remote sites provided urgent EKG diagnosis and tele-consultation that triggered ambulance dispatch and implementation of standardized AMI protocols. Results 784,947 patients were screened for AMI at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With this expanded geographic reach, 8,448 (1.08%) patients were diagnosed with STEMI and 3,911 (46.3%) urgently reperfused, including 3,049 (78%) with Primary PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Major reasons for non-treatment were insurance denials, lack of ICU beds and chest pain >12 hours. Conclusions LATIN demonstrates the feasibility of a population-based and telemedicine guided AMI strategy that can hugely expand access. Telemedicine has important public health implications as a global approach to AMI care in developing countries.

Abstract 3030: Meta-analysis of Cost Effectiveness of Different Stroke Unit Subtypes

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Minal Jain ◽  
Anunaya Jain ◽  
Abhijit R Kanthala ◽  
Babak S Jahromi
Keyword(s):  
Cost Effectiveness ◽  
Stroke Unit ◽  
Systems Of Care ◽  
Surrogate Marker ◽  
Cost Effective ◽  
Stroke Care ◽  
Developed Countries ◽  
Direct Care ◽  
Early Supported Discharge ◽  
Acute Rehabilitation

Aim: To perform a systematic review and metanalysis, comparing outcome and cost of stroke care in a stroke unit (SU) versus conventional care (CC). Secondary aim was to compare cost effectiveness of different SU subtypes. Methods: Pubmed search was performed for “Stroke Unit” among all English language articles from 01/01/1996 to 01/01/2011. Only articles from developed countries, reporting the length of stay (LOS) and/or cost and outcomes for ischemic stroke were included. Studies wherein data was collected before 01/01/1996, articles only on rehabilitation units, and all systematic reviews were excluded. LOS was taken as a surrogate marker of stroke care cost in studies wherein direct care costs were not reported. Non-QALY outcomes were converted to QALYs using reported logistic regressions. Ratios less than $50,000/QALY were considered cost effective while greater than $100,000 /QALY were considered non-cost effective. All cost were reported in 2010 US$. Result: A total of 5,537 articles in Pubmed were studied, of which 19 studies met the inclusion criteria. LOS for patients managed at SU ranged from 9.2-32.3 days versus 8-35.3 days for CC units and average incremental QALYs between them were 0.09. The average incremental cost/QALY was $41,204.37. The average cost/QALY for different types of SU were $19,428.64 for Acute only SU (A SU), $44,228.81 for Acute+Rehabilitation SU (A+R SU), $29,145.93 for Acute+Rehabilitation+Early Supported Discharge (A+R+ESD) SU and $20,460.56 for SU with Continuous monitoring (SU CM). In comparison to an A SU, SU CM and A+R+ESD SU were cost effective alternatives (ICER SU CM estimated at $25,120.89, ICER A+R+ESD SU estimated at $24,574.59). Conclusion: Stroke Units are cost effective when compared to the conventional systems of care. Acute + rehab SU with early supported discharge appears to be the most cost effective model amongst different subtypes of SU.

scholarly journals I farmaci per lo scompenso cardiaco: criteri di scelta razionale e costo-efficace

2005 ◽  
Vol 6 (3) ◽  
pp. 215-226
Author(s):  
Francesco Vittorio Costa ◽  
Lorenzo Pradelli
Keyword(s):  
Hospital Admissions ◽  
Beta Blockers ◽  
Inappropriate Prescribing ◽  
Cost Effective ◽  
Drug Market ◽  
Developed Countries ◽  
Point Of View ◽  
Cost Driver ◽  
Number Of Patients ◽  
Clinical Benefits

Chronic heart failure (CHF) is the final phase of many common cardiovascular diseases. Consequently, it represents a frequent clinical condition: it’s estimated that in developed countries, Italy included, its prevalence exceeds 3%. CHF is also burdensome from an economical point of view, as it absorbs more than 2% of the Italian total health care budget. The main cost driver in CHF, accounting for approximately two thirds of its total expense, is represented by hospital admissions for relapse. The most frequent reason for relapse, in turn, is inadequate treatment, intended both as low patient compliance to prescribed drug regimens and as inappropriate prescribing. Evidence-based guidelines for the optimal pharmacological treatment of CHF have been developed and are constantly updated, and it’s demonstrated that the stricter the adherence to these recommendations, the better the clinical and economic outcomes. Pharmacoeconomic studies conducted on the use of ACE-inhibitors and beta-blockers, in particular, have shown that correct therapeutic strategies can be cost-saving in CHF management, besides providing important clinical benefits. The expansion of generic drug market has brought by a reduction in pharmaceutical prices, allowing to offer the benefits of these highly effective, and cost-effective, treatments for CHF to a larger number of patients, without increasing the global pharmaceutical expense, but probably reducing the total economical burden of the disease.

P5241Balancing limited resources, infra-structure deficits & cultural differences in sustaining the growth of LATIN telemedicine program

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S Mehta ◽  
R Botelho ◽  
F Fernandez ◽  
F Feres ◽  
A Abizaid ◽  
...  
Keyword(s):  
Linear Growth ◽  
Large Population ◽  
Data Entry ◽  
Cost Effective ◽  
Population Based ◽  
Limited Resources ◽  
Delayed Presentation ◽  
Hub And Spoke ◽  
Process Metrics ◽  
Door To Balloon

Abstract Background In resource-constrained nations, population-based AMI coverage is daunting. Telemedicine can transform with efficient, cost-effective and scalable programs. We present our data with screening >780,000 patients with innovative hub and spoke strategies. Purpose Scientifically pristine protocols, rigorous training, unflinching quality assurance, technology upgrades and education of broad stakeholders are essential attributes for creating population-based AMI programs. Methods Latin America Telemedicine Infarct Network (LATIN) required methodical groundwork during a 12-month pilot prior to its formal launch and sustenance for 5 years. It involved scrupulous site selection, technology, and telemedicine optimization and system-wide process metrics. Spokes are the LATIN nucleus and require constant (3-T) training: Triage, Telemedicine, and Transportation. Plus, a mandatory deconstruct of their role in LATIN, of urgent transfer and desist non-critical care. Telemedicine requires constant upgrading of platform, tele-equipment and cloud computing. Ambulance availability is a constant challenge as is the battle with payers. Data entry has required meticulous training and oversight. Strict QA processes have monitored critical metrics: Spokes (Door In Door Out, DIDO and Transport Times); Hubs (Door to Balloon Times, D2B); Telemedicine Platform (Time to Telemedicine Diagnosis, TTD). Results Linear growth is observed in the number of sites and telemedicine screenings with simultaneous and sustained improvements in D2B and TTD. 784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min and in-hospital morality 5.2%. Major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation. Conclusions As other regions of the world develop large, population-based AMI management initiatives, LATIN can provide important lessons in the sustainability of these processes.

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